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Chapter3
Factorsinfluencing
antibioticprescribingin
longtermcarefacilities:
aqualitativeindepthstudy
LauraW.vanBuul
JennyT.vanderSteen
SarahM.M.M.Doncker
WilcoP.Achterberg
FrançoisG.Schellevis
RuthB.Veenhuizen
CeesM.P.M.Hertogh
PublishedinBMCGeriatr2014;14:136
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Abstract
Background: Insight into factors that influence antibiotic prescribing is crucial when
developing interventions aimed at a more rational use of antibiotics. We examined
factorsthatinfluenceantibioticprescribinginlongtermcarefacilities,andpresenta
conceptualmodelthatintegratesthesefactors.
Methods:Semistructuredqualitativeinterviewswereconductedwithphysicians(n=
13)andnursingstaff(n=13)infivenursinghomesandtworesidentialcarehomesin
the centralwest region of the Netherlands. An iterative analysis was applied to
interviewswithphysicianstoidentifyandcategorizefactorsthatinfluenceantibiotic
prescribing, and to integrate these into a conceptual model. This conceptual model
wastriangulatedwiththeperspectivesofnursingstaff.
Results:Theanalysisresultedintheidentificationofsixcategoriesoffactorsthatcan
influencetheantibioticprescribingdecision:theclinicalsituation,advancecareplans,
utilizationofdiagnosticresources,physicians’perceivedrisks,influenceofothers,and
influence of the environment. Each category comprises several factors that may
influencethedecisiontoprescribeornotprescribeantibioticsdirectly(e.g.pressure
ofpatients’familyleadingtoantibioticprescribing)orindirectlyviainfluenceonother
factors(e.g.unfamiliaritywithpatientsresultinginahigherphysicianperceivedriskof
nontreatment,inturnresultinginahighertendencytoprescribeantibiotics).
Conclusions: Our interview study shows that several nonrational factors may affect
antibiotic prescribing decision making in longterm care facilities, suggesting
opportunities to reduce inappropriate antibiotic use. We developed a conceptual
model that integrates the identified categories of influencing factors and shows the
relationshipsbetweenthosecategories.Thismodelmaybeusedasapracticaltoolin
longterm care facilities to identify local factors potentially leading to inappropriate
prescribing, and to subsequently intervene at the level of those factors to promote
appropriateantibioticprescribing.
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Factorsinfluencingantibioticprescribinginlongtermcarefacilities
Background
Antibioticsarecommonlyprescribedinnursinghomesandresidentialcarehomes.As
much as 47% to 79% of the people residing in these facilities receives at least one
course of antibiotics per year, of which a substantial part in situations where
antibiotictreatmentisnotindicated.1Thisinappropriateantibioticusecontributesto
the development of antibiotic resistance, which is also common in longterm care
settings. These insights have led to awareness regarding appropriate use of
antibiotics,andtoseveralinitiativestopromoterationalantibioticprescribing.
Tobeeffective,interventionsaimedatamorerationaluseofantibioticsshouldtake
into account the factors that impede and facilitate appropriate prescribing. Such
factors may apply to the patient, the physician, the care setting, and the larger
cultural and socioeconomiccontext.2 Factors thatinfluenceantibiotic prescribing in
general practice and hospitals have been studied extensively. Examples of such
factorsincludepatients’symptomsandresultsofphysicalexamination,availabilityof
resources,availabilityandawarenessofevidencewithregardtoantibiotictreatment,
diagnostic uncertainty, peer practice, patient expectations, financial interests, and
physicians’ perceptions regarding antibiotic prescribing and resistance.214 The
diversity of these factors indicates that the antibiotic prescribing decision can be
complexinthesesettings.
Less research has been conducted on factors that influence antibiotic prescribing in
nursinghomesandresidentialcarehomes.Whereasseveralfactorsidentifiedforthe
generalpracticeandhospitalsettingarelikelytobevalid–atleastpartly–inlong
term care settings, other factors may be involved that relate to the specific
characteristics of these facilities, the physicians delivering care, and the patient
population.Afewstudiesquantitativelyinvestigatedassociationsbetweenantibiotic
prescribing and possible determinants in longterm care facilities.1520 These found
thatprescribingdecisionscanbeaffectedby,forexample,theseverityofillnessand
the ability to communicate with residents. Other studies qualitatively investigated
factors that influence antibiotic prescribing for specific conditions (i.e. urinary tract
infectionandpneumonia),andreportedthatantibioticprescribingdecisionsmaybe
influenced by nursing staff, family wishes, and familiarity with the patient.2123 To
date, factors that influence antibiotic prescribing in general have not been
qualitativelyexploredindepthinlongtermcarefacilities.
Basedonqualitativeinterviewswithphysiciansandnursingstaff,thisstudytherefore
examines factors that influence antibiotic prescribing in general in longterm care
facilities in the Netherlands, where prevalence of antibiotic prescribing is high
comparedtoambulatorycaresettingsandaverageincomparisonwithlongtermcare
facilities in other European countries.24,25 We present a conceptual model that
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integrates these factors, which may guide the development and implementation of
interventionsaimedatrationalizingantibioticuseinlongtermcarefacilities.
Methods
Studysetting
The current interview study is part of a research project aimed at rationalizing
antibiotic prescribing in longterm care facilities: the IMPACT study.26 The IMPACT
studywasconductedin14longtermcarefacilities,ofwhichsevenwereallocatedto
an intervention group and seven to a control group. In the interview study, which
preceded implementation of interventions to improve prescribing practices, we
includedonlyfacilitiesfromtheinterventiongroup(5nursinghomesand2residential
care homes), to avoid undue influence of participation in qualitative research
activitiesonprescribingbehaviorincontrolgroupfacilities.
IntheNetherlands,organizationofmedicalcarediffersbetweennursinghomesand
residentialcarehomes.Nursinghomesemployelderlycarephysicians(formerlycalled
nursing home physicians), which is a distinct medical specialty in the Netherlands.
Medical care in residential care homes is provided by general practitioners, who
operatefromtheirownpractice.Intervieweeswerefrombothcaresettings.
AllparticipatingfacilitieswerelocatedinthecentralwestregionoftheNetherlands.
Asampleof13outofapproximately30physicianswaspurposefullyselectedbythe
researchers to reflect variation in sex, age, years of professional experience, and
professional specialism. One of the 13 initially selected physicians was not able to
participate in an interview due to time constraints, and another physician was
selected instead. The physicians in this final sample all provided written consent to
participateintheinterviews.Asampleof13nursingstaffmemberswasadditionally
selectedbyresearcherswiththehelpofalocationmanager,aphysician,oramedical
secretary,similarlypursuingvariation.Theseparticipantsprovidedconsentinperson
priortothestartoftheinterviews.
Datacollection
Ateamof researchers (LB,JS,SD,FS,CH) developedtwo topic lists (Additional file),
oneforphysiciansandonefornursingstaff,basedonfieldexperienceoftheproject
team,relevantliteratureonfactorsassociatedwithdrugprescribing,andaliterature
based conceptual model developed by Zimmerman et al.27 Both topic lists aimed at
exploring perceptions and motivations with regard to three themes: infectious
diseases, antibiotic prescribing, and antibiotic resistance. For the theme ‘antibiotic
prescribing’, respondents were asked to describe two recent cases: one in which
antibiotics were prescribed and one in which antibiotics were not prescribed. The
topic list was used to raise follow up questions to determine factors influencing
prescribingdecisions.
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Factorsinfluencingantibioticprescribinginlongtermcarefacilities
Onesemistructuredinterviewperrespondentwasconductedbytrainedinterviewers
(LB and SD). To achieve concordance, the interviewers conducted the first two
interviewstogether.Allinterviewsweretaperecordedandtranscribedinfull,andwe
removed any information from which the particular respondent or longterm care
facilitycouldbeidentified.
Dataanalysis
We started the analysis with the recent cases that were described by physicians, as
theseconstitutedthebasisoftheinterviews.Thesecasedescriptionswerestudiedby
tworesearchers(LBandSD)toidentifyandcategorizefactorsthatinfluenceantibiotic
prescribingdecisions.Theresultingcategorieswereregardedasbasicconsiderations
for treatment decisions (i.e. they are generally considered in treatment decisions),
andwerethereforeconsideredthecoreofaconceptualmodel.Aniterativeanalysis
was applied to further elaborate this conceptual model. Hereby, the remaining
materialofthephysicianinterviews–whichcontaineddescriptionsofotherpractice
situationswithregardtoantibioticprescribingdecisions–wasstudiedinastepwise
fashion:1)fragmentsofthematerialwerelabelledaccordingtotheircontent(open
coding), 2) relationships were sought between the coded fragments (axial coding),
and3)therelatedcodedfragmentswerecategorized(selectivecoding)andaddedto
theconceptualmodel.
Open coding was conducted by two researchers (LB and SD), who independently
codedtranscriptsof3physicianinterviews,anddevelopedaseparatecodelist.These
codelistswerecompared,discussed,andcombinedintoacollectivecodelist.The3
previouslycodedtranscriptsandtheremaining10transcriptswere(re)codedbyeach
researcheraccordingtothecollectivecodelist.Aftereachthirdcodedtranscript,the
researchers compared and discussed the transcripts and – where necessary – codes
were added or adjusted according to reached consensus. Coding of the last few
transcriptsyieldednonewcodes,whichindicatesdatasaturation.Axialandselective
coding was conducted by one of the researchers (LB), and discussed with the other
researcher (SD). The qualitative data analysis software program Atlas.ti, version 6
(ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) was used to
processthecodedtranscripts.
Sincephysiciansareresponsiblefortheprescribingdecision,thephysicianinterviews
were used for the initial development of the conceptual model. Subsequently, this
modelwastriangulatedwithperspectivesderivedfromthe13codedinterviewswith
nursing staff. The coding procedure of these interviews was identical to and
independentoftheprocedureofthephysicianinterviews.Theinformationretrieved
from the interviews with nursing staff was used to support and enhance the
understandingofantibioticprescribingdecisionsmadebyphysicians.Inaddition,the
conceptualmodelwasstudiedbyallmembersofthestudyteamandadjustmentsto
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themodelweremadeuponcriticaldiscussionoftheanalyticstepsandinterpretation
oftheresults.
Ethicalapproval
TheIMPACTstudywasapprovedbytheMedicalEthicsReviewCommitteeoftheVU
UniversityMedicalCenter(Amsterdam,theNetherlands).
Results
Table 1 shows the demographic characteristics of the interviewed physicians and
nursing staff; there was substantial variation in age (range: 24 – 61) and years of
professionalexperience(range:0–36).Thedurationoftheinterviewsvariedfrom19
minutes to 53 minutes, with a mean of 34 minutes overall (physicians: 39 minutes,
nursingstaff:30minutes).
Table1.Demographicsoftheinterviewedphysiciansandnursingstaff.
Demographic
Sex
Age(yr)
Yearsof
professional
experience
Typeoffacility
Male
Female
Mean(range)
Mean(range)
Physicians(n=13)
4
9
45(25–60)
15(0–36)
Nursingstaff(n=13)
1
12
45(24–61)
17(0–32)
Overall(n=26)
5
21
45(24–61)
16(0–36)
Nursinghome
Residentialcarehome
Urbanarea
Ruralarea
Nursinghome
10
9
19
3
4
7
Facilitylocation
8
7
15
6
11
5
*
Professional
Elderlycarephysician(7)
Nurse (4)
Nurseassistant*(5)
specialism
Elderlycarephysicianintraining(1)
Juniordoctor(1)
Physicianassistant(1)
Residentialcarehome
Generalpractitioner(3)
Nurseassistant* (4)
*UnitedStatesequivalents:nurse=registerednurse,nurseassistant(levels2,3and4)=licensedpracticalnurse(level4)ornurseaid(levels2and3).
Theanalysisofrecentcasesthatweredescribedbyphysiciansledtotheidentification
oftwocorecategoriesoffactorsthatinfluencetheantibioticprescribingdecision:the
clinicalsituation,andadvancecareplans.Thesecategorieswerealsoderivedfromthe
analysisofotherpracticesituationsthatphysiciansdescribedwithregardtoantibiotic
prescribing. The latter analysis additionally resulted in the identification of the
following categories: utilization of diagnostic resources, physicians’ perceived risks,
influenceofothers,andinfluenceoftheenvironment.Figure1showsourconceptual
modelthatintegratesthesecategoriesanddemonstrateshowtheyareinterrelated.
Interviews with nursing staff supported the identified categories and added no new
informationtothemodel.Thecategoriesoffactorsthatwereidentifiedasinfluencing
theantibioticprescribingdecisionaredescribedinmoredetailbelow.
Clinicalsituation
Boththecurrentclinicalsituationandthepatients’medicalhistoryappearedtoplaya
crucial role in the decision to prescribe or not prescribe antibiotics. Table 2 shows
considerationswithregardtotheclinicalsituationthataffecttheprescribingdecision
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Factorsinfluencingantibioticprescribinginlongtermcarefacilities
for urinary tract infection, respiratory tract infection, and skin infection. Two
situations were described in which the clinical situation can be unclear: 1) when
Table2.Elementsoftheclinicalsituationthatresultinthedecisiontoprescribeornotprescribeantibioticsforurinary
tractinfections,respiratorytractinfections,andskininfections.
Clinicalsituation
Current
Antibiotic
Yes
No
Medicalhistory
Yes
No
Urinarytractinfection
Signsandsymptoms(orahighrisk
ofsignsandsymptoms),
positivedipsticktest(for
leukocyteesterase,nitrite,or
both)/dipslide/culture,
patientexperiencesburden,
patientfeelsill,hematuria,
vulnerabilityofthepatient,
comorbidity,nopriorantibiotic
resistance
Absenceof(relevant)signsand
symptomswhetherornotin
combinationwithapositive
dipsticktest(forleukocyte
esterase,nitrite,orboth),
negativedipsticktest,awaiting
cultureresultsincaseof
no/minimalsignsand
symptoms,patientdoesnot
feelill,poorprognosis,
acceptanceofresistant
bacteriainurine
Positiveeffectoftreatmentfor
previousinfection,no/limited
historyofinfection,ineffective
previoustreatment
Respiratorytractinfection
Signsandsymptoms,patientfeels
ill,vulnerabilityofthepatient,
riskofdeath,comorbidity
Skininfection
Signsandsymptoms,
vulnerabilityofthe
patient
Absenceof(relevant)signs
andsymptoms
Poorprognosis,suspectedviral
infection,no/minimalsigns
andsymptoms,patientdoes
notfeel(severely)ill,physical
inabilitytotakeoral
medication,allowingimmune
systemofthepatienttoclear
infection
Severecourseofpreviousinfection
Nohistoryofinfection
communication with patients is impaired, which is common in residents with
dementia, and 2) when (typical) clinical signs and symptoms are absent. Such
situationsresultindiagnosticuncertainty,whichcaneitherpromoteantibioticuseif
uncertainty leads to prescribing, or impede antibiotic use if uncertainty leads to
furtherobservingthecourseofinfection.Accordingtotheinterviewedphysicians,a
reason for not prescribing antibiotics for urinary tract infection is the absence of
clinical signs and symptoms despite a positive dipstick test (i.e. the presence of
leukocyte esterase, nitrite, or both). Some physicians expressed dissatisfaction with
nursing staff performing a dipstick test in such situations, especially when the
rationaleforthetestwasachangeinurineodororappearance.Nursingstaff,onthe
other hand, may not always be aware of this dissatisfaction, as some respondents
indicatedachangeinurineodororappearanceasareasontoperformadipsticktest.
Thisisillustratedinthefollowingquotations:
Elderlycarephysician,female,53:“Thenursescallout‘yes,theurinestinks’.Andsotheystarted
dipsticktesting[theurine].AndIsay‘wellIamnottreatingurine,Iamtreatingthepatient’.”
Nurse, female, 53: “Sometimes the urine is checked because it is just very nasty. Very
concentrated,oritsmellsreallybad.”
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Advancecareplans
Theinterviewsshowedthatadvancecareplanscanplayacentralroleinthedecision
making process in nursing homes (they were not mentioned for residential care
homes). These include the documentation of considerations to guide future (non)
treatmentdecisions,asformulatedbythephysicianandthepatientorthepatients’
family. Antibiotic treatment may be included in the advance care plan, thereby
anticipating situations in which antibiotic treatment potentially prolongs life. The
interviewed physicians consulted the advance care plan when a patient develops a
potentiallylifethreateninginfectionsuchaspneumonia.Theystatedtonotprescribe
antibioticswhentheoverallcaregoalintheadvancecareplanwasdefinedascomfort
ratherthanlifeprolongation.
Utilizationofdiagnosticresources
Theinterviewsdemonstratedthattheextenttowhichphysiciansresorttodiagnostic
resources is limited in longterm care facilities. Consequently, physicians have less
information to judge a clinical situation compared to situations in which additional
diagnostic information would be available, which in turn contributes to diagnostic
uncertainty. We abstracted from the interviews four explanations for not using
diagnosticresourcestofacilitatetreatmentdecisions.First,certaindiagnosticscanbe
tooburdensomeforthevulnerablelongtermcarepopulation(e.g.referringapatient
tothehospitalforfurtherinvestigation).Asecondexplanationincludestheinabilityto
obtainagoodsputumorurinesampleforculturefromelderlypatients.Inaddition,
logisticconsiderationscanbeinvolvedinthedecisionnottousediagnosticresources.
In this regard, physicians pointed to a lack of onsite diagnostic resources (e.g. C
reactive protein pointofcare test, Xray, urine culture), difficulties to consult the
laboratory outside regular visit days for collection of specimen of residents, higher
workload for the physician when taking cultures, and the length of time needed to
obtain laboratory culture results (i.e. approximately one week). Finally, financial
considerations can also be involved, in particular related to laboratory costs of
cultures.
Physicians’perceivedrisks
Theinterviewsshowedthatrisksperceivedbyphysicianscaninfluencetheantibiotic
prescribing decision. These can be divided into perceived risks of treatment and
perceivedrisksofnontreatment.Withregardtoperceivedrisksoftreatment,some
physiciansdescribedsituationsinwhichtheriskofsideeffectswasmentionedasone
ofthereasonstonotprescribeantibiotics.Further,somephysiciansraisedtheriskof
antibiotic resistance development, which was considered from two points of view.
The first point of view was that antibiotics should not be prescribed because of the
risk of antibiotic resistance, if the clinical situation does not necessarily require
antibiotic treatment. The second perception was that antibiotic resistance is not an
important consideration in antibiotic prescribing, as the vulnerable longterm care
populationhasashortlifeexpectancy.Forexample:
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Factorsinfluencingantibioticprescribinginlongtermcarefacilities
Generalpractitioner,female,38:“…ifthegentlemanisgoingtodieanywaythenanyantibiotic
resistanceisnotrelevant.Soinmymindthatissomethingofamitigatingthing.”
Perceived risks of nontreatment appeared to influence the antibiotic prescribing
decision especially when physicians experience uncertainty, for example due to
diagnosticuncertaintyorunfamiliaritywiththepatient.Weidentifiedthreesituations
in which perceived risks of nontreatment resulted in treating more readily with
antibiotics. The first situation involves a perceived risk of adverse outcomes. For
example:
Generalpractitioner,female,47:“SoevenifIinitiallythinkwellit’sonlyviral,butIfeelthereisa
verysubstantialriskofasuperimposedinfectionincasetheyhavearespiratoryinfection,thenI
amjustveryquick[toprescribeantibiotics].”
The second situation involves a perceived sense of alarm (i.e. a “gut feeling”). For
example:
Elderly care physician, female, 36: “… if I am not completely sure and I simply don’t trust the
situation,thenIwill[prescribeantibiotics].InthatcaseIthinkwell,bettersafethansorry.”
Thethirdsituationinvolvesaperceivedriskofnotfulfillingthepatients’expectations.
Thequotationbelowshowsthatthephysicianperceivesthatthepatientexpectsher
to“dosomething,”whichsheinterpretedastheprescriptionofanantibiotic:
Elderlycarephysicianintraining,female,25:“IfIdon’ttakeactionitlookslikeIdon’twantto
helpthepatient,butperhapsIalreadyknow,wellisitgoingtoworkatall?”
Influenceofothers
Physicians described several situations that showed influence of others on the
prescribing decision. These can be colleagues, the patient, the patients’ family, and
nursingstaff.Somesituationsshowedthatphysiciansmaybemoresusceptibletothe
opinion or wish of others in uncertain situations. Vice versa, the opinion or wish of
othersmayalsoaffectthedegreeofuncertaintyexperiencedbyphysicians.
Three situations in which colleagues influenced the prescribing decision were
described: 1) following the advice of a colleague when in doubt about whether to
treatwithantibioticsornot,2)anagreementtotreatpatientsaccordingtothehabits
ofacolleaguewhencoveringforthiscolleague,3)adaptationtoprescribinghabitsof
peers.Thelatterisillustratedbythefollowingquote:
Physician assistant, male, 51: “That is during the weekend […] and then almost everybody
prescribesAugmentin[i.e.amoxicillinclavulanate].That’swhy.Thatwasmymotivationtoo.”
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Physicians and nursing staff described several situations in which patients or the
patients’ family expressed their wish with regard to the treatment of an infection.
Basedonthesedescriptions,weidentifiedthreescenariosofhowphysicianshandle
thesesituations:1)physiciancomplieswithawishnottotreat,2)physiciancomplies
withawishtotreat,and3)physiciandoesnotcomplywithawishtotreat.Theseare
describedandillustratedwithrelevantquotationsinTable3.
Table3.Scenariosofhowphysicianshandlesituationsinwhichpatientsorthepatients’familyexpresstheiropinionor
wishregardingthetreatmentofaninfection.
Scenario
PhysicianCOMPLIES
with
patients’/family’s
WISHNOTTOTREAT
PhysicianCOMPLIES
with
patients’/family’s
WISHTOTREAT
Descriptionofsituation
Physiciansindicatetonotprescribeantibiotics
whenthepatientorhis/herfamilydoes
notwantlifeprolongingantibiotic
treatment(oftenrecordedinadvancecare
plans).
Antibiotictreatmentisconsiderednecessaryby
physician.
Antibiotictreatmentisconsidered(partly)
medicallyfutilebyphysician,but:
x familywantstohavetimeto
deliberatewithafamilymemberthat
cannotbereached,incaseofapoor
prognosisofthepatient.
x physicianiswillingtoconcedetothe
wishoffamilyduetounfamiliaritywith
thepatientandinabilitytopredictthe
outcome.
x
physicianconsidersitunethicallyto
ignorethereligionbasedwishofthe
patient/family,incaseofapoor
prognosisofthepatient.
x
aperceptionthatscientificresearch
showedthattheoutcomeofa
pneumoniaisnotmuchinfluencedby
treatmentwithantibiotics[incaseof
respiratorytractinfectionsattheend
oflife].
familyshouldbeallowedtimetoget
usedtotheideathattheconditionofa
patientdeteriorates.
x
x
PhysicianDOESNOT
COMPLYwith
patients’/family’s
WISHTOTREAT
patientsonrehabilitationunitsare
usedtogetantibioticsfromtheir
generalpractitionerandwillconsult
thisgeneralpractitionerifnoantibiotic
isprovided.
Antibiotictreatmentisconsideredmedically
futilebyphysician.
Familyofamentallycompetentpatientwants
treatmentwhereasthepatientdoesnot
wanttreatment.
Relevantquotations
Juniordoctor,female,30:“…ifthefamilyreallydecidesnottodo
it[treatwithantibiotics],thentheyaccepttheriskthathe
[thepatient]willdieasaresultofit.AndwhoamItosaywell
Iamgoingtogiveantibioticsanyway.Atthatpointthatisnot
myrole.ThenIjusthavetoacceptwhattheywant.”
Elderlycarephysicianintraining,female,25:“…thenIdecidedin
consultationwithhissontostarttheantibiotics[…]because
anothersonwasonholiday[…].Andwecouldn’tgetaholdof
himonthephone.”
Juniordoctor,female,30:“…ifthey[thefamily]insist,thenwe
shoulddoit[prescribeantibiotics]becauseIdon’tknowthe
man.Soit’sdifficulttopredict.Ithinkitwon’tmakemuchofa
difference,butstill,ifthefamilyreallyinsists,thenIamquite
willingtoprescribe[antibiotics].”
Generalpractitioner,female,38:“…Ithinkitisveryunethicalto
sayatamomentlikethatI’msorry,butyouarenotgetting
them[antibiotics].Evenifeverythinginmesaysyou’renot
goingtomakeit,thisisliterallythelastmile,butthe
gentlemanfeelslike‘I’vedoneeverything,ifIdienowthenit
mustbeGod’swill’.”
Elderlycarephysician,male,51:“…nowwealsoknowfrom
scientificresearchthatifyoutalkaboutpneumoniathatthe
outcome[…]isnotreallydeterminedbywhetheryouusean
antibioticornot.Andthatmakesitalittleeasierforustogive
itevenwhenyouthink‘well,ifitwasmymotherIwouldn’t
havedonethis’.”
Elderlycarephysician,male,48:“…Ijusthappenedtohavehad
somepatientsrecentlyofwhomIthoughtinretrospectIjust
shouldn’thavedoneit[prescribedantibiotics].Butsometimes
youdoitforthefamily.[…]InthepastIusedtobemore
principledaboutthis,Iwouldsaylook,youshouldn’tdothis,
andnowIthinkwell,it’saprocessforthemtooandIdotell
them[thatthereisnotmuchpoint],butiftheycan’tgoalong
withthatyetthenIdon’tpushharder.”
Nurseassistant,female,35:“[Thatisbecause]peopleareabit
morearticulateofcourse[ontherehabilitationunit]:‘[…]I
justhaveaurinarytractinfection’.Andthisistreatedinthe
homesituation.Sosometimesthatisthereasonthatthe
physiciandoestreatithere,sometimes[…]”
Elderlycarephysician,female,53:“…andsomepatients[…]then
demandtreatment.[…]WhenIamconvincedthat‘thisis
pointless,thisismedicallycompletelypointless’.ThenIdon’t
doit[prescribeantibiotics].”
Elderlycarephysician,female,53:“Wellitdepends[…],if
someoneiscompetent.Andthispersonsays‘no’[no
antibiotics]butthefamilysays‘yes’[giveantibiotics],thenI
alsosayIwon’tdothat.Becauseyourmotherisquiteclear
aboutit.”
Theinterviewsshowedindirectanddirectinfluenceofnursesandnurseassistantson
treatment decisions of physicians. Indirect influence includes the dependence of
physiciansonnursingstaffforinformationabouttheclinicalsituationofapatient:the
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Factorsinfluencingantibioticprescribinginlongtermcarefacilities
poorer the quality of the information or the conveyance of information, the more
difficultitcanbeforaphysiciantoassesstheclinicalsituationandmakeatreatment
decision.Physicians’opinionsdifferedaboutthequalityofinformationobtainedand
conveyed by nursing staff. Some mentioned that nursing staff is wellcapable of
recognizing signs of infection and judging when the physician should see a patient,
others indicated that the quality of information and conveyance of information
dependsontheexperienceandlevelofeducationofthenursingstaffmember.The
quality of information conveyance can also be influenced by the work schedule of
nursingstaff;staffthathadthepreviousdaysoffmaynotbeasinformedaboutthe
clinicalsituationofapatientasstaffthatpersonallywitnessedthecourseofillness.
Furthermore, some physicians mentioned that their treatment decision is often
complicated by the omission of nursing staff to register the patients’ temperature,
bloodpressure,andpulse.
With regardto direct influenceof nursing staff, several situations weredescribed in
whichnursingstaffexpressedarequestforantibiotictreatment.Forexample:
Nurse, female, 53: “Then I sometimes call directly to say ‘there are unmistakable signs of an
infection,comeandprescribeantibiotics’.”
Whereas some physicians reported not to comply with such requests in situations
where they considered antibiotic treatment medically futile, others indicated that
they value and comply with the opinion of nursing staff in certain situations, for
example:
Elderlycarephysician,female,36:“WhenanursehasseriousconcernsIthinkIwouldbemore
tempted to prescribe an antibiotic, […] Nurses are often good judges of patients because they
knowthemmuchlongerthanIdo.”
Influenceoftheenvironment
The interviews demonstrated that the antibiotic prescribing decision can be
influencedbyseveralenvironmentalfactors.Theseincludetheavailabilityofevidence
with regard to treatment of infections. Some physicians reported that treatment
decisionsarecomplicatedbyalackofprescribingguidelinesfortheolderpopulation,
andalackofinsightintolocalresistancepatterns.Anotherenvironmentalfactoristhe
lackofonsitediagnosticresources,whichcontributestothelimitedextenttowhich
diagnostic resources are utilized. In addition, limited accessibility of information in
medical files can complicate antibiotic prescribing decision making. Two other
environmentalfactors,whichareoftenrelated,aretheorganizationofcrosscovering,
andfamiliaritywithpatients.Somephysiciansindicatedthattheytendtotreatmore
readilywithantibioticswhenoncall,duetounfamiliaritywithpatients:
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Elderlycarephysician,female,57:“Wehavediscussedthiswiththepartnersinourcallgroup.
Thatyouaremuchquickertogiveantibioticsintheweekends.Justbecausethesepatients,these
familiesarestrangers.Youdon’tknowthemverywell.”
Further, the conduction of telephoneconsultations can affect the degree to which
others influence treatment decisions. For example, some physicians indicated that
theyaremoredependentonnursingstaffincaseofatelephoneconsultation.Afinal
environmentalfactorthatcaninfluenceantibioticprescribingdecisionsisthedayof
theweekaconsultationtakesplace.Forexample:
Elderly care physician, male, 48: “Fridays it’s always more difficult than on Mondays [to use
antibioticsprudently].[…]onFridaysIthink[…]well,someoneelseisgoingtocomeinandhave
a look [during the weekend], he won’t be able to compare and will prescribe the antibiotics
anyway, so I might as well prescribe it today. Otherwise this colleague will have to come in
especiallytomorrow.”
Figure1.Conceptualmodeloffactorsthatinfluenceantibioticprescribinginnursinghomesandresidentialcarehomes
in the Netherlands. The model shows that the clinical situation and advance care plans constitute the basis of the
antibioticprescribingdecision.Theotherfourcategoriescanexertadirectinfluenceonthisprescribingdecision,oran
indirectinfluenceviaothercategories.Theclinicalsituationcaninfluencetheuseofdiagnosticresources(e.g.noXray
when a patient is severely ill) and vice versa (e.g. less information about the clinical situation when no diagnostic
resourcesareused).Theuseofdiagnosticresourcescanalsobeinfluencedbyenvironmentalfactors(e.g.availabilityof
onsitediagnosticresources).Physicians’perceivedriskscanbeinfluencedbytheclinicalsituation(e.g.higherperceived
riskofnontreatmentifapatientisseverelyill),theuseofdiagnosticresources(e.g.moreuncertaintyifnodiagnostic
resourcesareused),others(e.g.pressurefrompatients),andtheenvironment(e.g.differentriskperceptionswhenon
call).Theinfluenceofotherscanbeaffectedbytheenvironment(e.g.theinfluenceofnursingstaffmaydifferwhena
consultationisbytelephonecomparedtoaphysicalconsultation).
Discussion
Qualitative interviews with physicians and nursing staff in seven longterm care
facilities in the Netherlands showed the following categories of factors that can
influence antibiotic prescribing decisions: the clinical situation, advance care plans,
utilizationofdiagnosticresources,physicians’perceivedrisks,influenceofothers,and
influence of the environment. Indepth analysis of these categories showed several
56
Factorsinfluencingantibioticprescribinginlongtermcarefacilities
factors that may result in inappropriate antibiotic prescribing decisions, such as risk
avoidance(‘bettersafethansorry’),adaptationtopeerpractice,andpressureexerted
bypatients,familymembersornursingstaff.Wedevelopedaconceptualmodelthat
integratesthecategoriesoffactorsanddemonstrateshowtheymayinterrelate.This
model may be used as a practical tool, whereby facilities explore which local non
rational factors influence their prescribing patterns, and subsequently intervene at
thelevelofthosefactorstopromoteappropriateprescribing.
Weidentifiedtheclinicalsituationandadvancecareplansasthetwocorecategories
of factors that influence antibiotic prescribing, and these therefore constitute the
basisoftheconceptualmodel.Inlinewithourfindings,thesecategorieswereamong
the most important factors in a Dutch study that quantitatively investigated
treatment decisions with regard to pneumonia in nursing home residents with
dementia.18 We are not aware of any other studies that investigated the role of
advancecareplansintheantibioticprescribingdecisionmakingprocessinlongterm
care.Futureresearchmayfurtherelucidatethisrole.
A lack of onsite diagnostic resources was previously described to result in limited
utilizationofdiagnosticresourcesinlongtermcarefacilities.22,2830Otherfactorsthat
reportedlycontributedtothislimitedutilizationincludethelengthoftimeneededto
obtain laboratory results, and difficulties in obtaining appropriate specimens for
culture, which corresponds with our findings.22,30 In addition, another Dutch study
described limited use of procedures such as xray examination in the vulnerable
nursinghomepopulation,whichindicatesthattheburdenofdiagnosticmeasuresfor
residents can be a reason not to use these.19 Limited utilization of diagnostic
resourcescontributestodiagnosticuncertainty.Wefoundthatothercontributorsto
diagnosticuncertaintyincludeimpairedcommunication,andabsenceofclinicalsigns
andsymptoms,whichissupportedbyotherlongtermcarestudies.21,29,30
Our finding that nursing staff, patients, and family can influence the antibiotic
prescribing decision corresponds with previous longterm care studies.16,18,2023 We
foundthatmostofthesituationsinwhichphysicianscompliedwithfamilywishesto
prescribe antibiotics involved endoflife situations. Other situations in which
physicianstooktheopinionofothersintoaccountincludeuncertainsituations,which
issupportedbyaDutchstudyontreatmentdecisionsfornursinghomeresidentswith
dementia who develop pneumonia.18 The influence of patients and family members
onantibioticprescribingdecisionscandifferbetweencountries.Forexample,itwas
foundthatprescribingdecisionsofphysiciansintheUnitedStatesweremorestrongly
guidedbyfamilywishesthanwerethoseoftheirDutchcounterparts.18,23
Other previouslyreported factors that can influence prescribing decisions in long
term care includephysiciansbeing moreinclined to prescribe antibioticsjust before
theweekend,22andphysicianfamiliaritywiththepatientorthepatients’family.20In
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ourstudy,alackoffamiliaritywiththepatientorthepatients’familyappearedtoplay
a role particularly when a physician was crosscovering, and less so during regular
work hours. This is likely due to the organization of nursing home care in the
Netherlands;elderlycarephysiciansareemployedbythenursinghome,andastheir
main site of practice, this facilitates thedevelopment of a relationship between the
physician and their patients and patient’s family, and ensures that the physician is
wellawareoftheirtreatmentpreferences.31Incountrieswherephysicianpracticein
nursing homes is often organized differently, such as in the United States,
unfamiliarity with nursing homes residents is common.20,23 In line with our findings,
unfamiliaritywithpatientscanpromoteantibioticprescribingduetofearsofadverse
outcomes.21
Some of the factors we identified in the present study have, to our knowledge, not
beendescribedbeforeforthelongtermcarepopulation,buthavebeenreportedin
the general practice or hospital setting. These include a lack of insight into local
resistancepattersandalackofawarenessofprescribingguidelines.3,4,9,12Inaddition,
prescribinghabitsofpeers,alsoreferredtoas“prescribingetiquette”,wasreported
as an importantfactorin the antibioticprescribing decisionin hospitalsandgeneral
practice.7,10,13 Other factors previouslyreported in these settings are related to
physicians’ perceived risks. In line with our findings, the risk of antibiotic resistance
developmentinfluencedtheprescribingofaminorityofphysiciansintwoqualitative
generalpracticestudies.7,12Furthermore,theriskofadverseoutcomesincaseofnon
treatment, and a perceived duty towards the patient were previously reported to
influenceprescribingdecisions.24,710
Two factors that were reported to influence antibiotic prescribing in other settings
were not found in the present study. We did not identify disagreement or distrust
with regard to existing evidence,7,10,11 which may be explained by the opinion of
interviewed physicians that there is not enough evidence regarding treatment of
infectionsinlongtermcare.Second,theinterviewsdidnotshowevidenceofadirect
influenceoffinancialconsiderationsonantibioticprescribing.3,10However,regarding
utilization of diagnostic resources, financial considerations were mentioned in the
presentstudy,andsomayaffectantibioticprescribingindirectly.
A strength of the current study is that the antibiotic prescribing process was
investigated from the perspective of both physicians and nursing staff. As these
parties collaborate and depend on each other in daily practice, we believe that our
findings provide a good insight into factors that influence antibiotic prescribing in
longterm care facilities. An additional strength is that we focused on recent case
descriptions in the interviews, and subsequently explored other practice situations.
This approach facilitates a realistic representation of daily practice with regard to
antibioticprescribingdecisions.
58
Factorsinfluencingantibioticprescribinginlongtermcarefacilities
Alimitationofthestudy,inherenttoqualitativeresearch,isthatnoassumptionscan
be made regarding the weight that each identified factor adds to the prescribing
decision.Futurequantitativeresearchisneededtoelucidatethecontributionofeach
factor to the antibiotic prescribing decision. Another limitation is that our study
design did not allow for checking data saturation at the time of data collection.
However, no new codes appeared when coding the last few interviews, which
supports that a sufficient amount of data was collected for drawing conclusions on
thistopic.
Aproperanalysisofrelevantfactorsthatinfluenceantibioticprescribingiscrucialfor
thedevelopmentofanantibioticprescribingimprovementprogram.3Severalstudies
show that interventions that target factors that impede appropriate antibiotic
prescribingarelikelytobemoreeffective.3234Theconceptualmodelpresentedinthis
studymaybeusedasapracticaltool,wherebyfacilitiesexplore,foreachcategoryin
the model, whichfactorsinfluencelocal antibiotic prescribing,and identifywhichof
these are inappropriate. Subsequently, they can intervene at the level of
inappropriate factors to promote rational antibiotic prescribing. For example, if
pressure exerted by patients is identified as a factor leading to inappropriate
prescribing,interventionssuchaspatienteducationcouldbeimplementedtoaddress
thisfactor.Factorsresultingininappropriateprescribingmaydifferbetweenfacilities
and nations.For instance,influenceof nursing staff onthe prescribingdecisionmay
be more important in facilities where – unlike in the Netherlands – no onsite
physiciansarepresent,andwheremanyconsultationsareconductedbytelephone.In
addition, the extent to which diagnostic resources are used may differ between
facilities, with some facilities having better access to such resources than others.
Whereas the importance of each factor in decision making may differ between
facilities and nations, we believe that our model in general is likely to be widely
applicable as many of the factors that we incorporated in the model have been
reported in a variety of settings and countries. In addition, it shows overlap with a
literaturebased prescribing decision model developed in a longterm care study
conductedintheUnitedStates,27aswellaswithelementsofamoregeneralmodel
forphysicianadherencetoclinicalpracticeguidelines.35
Conclusions
Ourqualitativestudyshowsavarietyoffactorsthatinfluenceantibioticprescribingin
longterm care facilities, of which several may lead to inappropriate antibiotic use.
Some of these factors have not been previously reported for the longterm care
setting, but have been described in studies in the general practice and hospital
setting,indicatingthatseveralfactorsinvolvedinthesesettingsalsoapplytothelong
term care setting. We developed a conceptual model that shows the relationships
betweentheidentifiedfactors.Thismodelmaybeusedasapracticaltooltoidentify
local factors potentially leading to inappropriate prescribing, to guide the
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development of antibiotic prescribing improvement programs that target these
factors.
Acknowledgements
Theauthorsthankthephysiciansandnursingstaffwhoparticipatedintheinterviews
andsharedtheirexperiencesandperceptions.TheauthorsacknowledgeprofPhilipD
SloaneandprofSherylZimmerman,oftheUniversityofNorthCarolinaatChapelHill,
fortheircontributiontotheconceptionanddesignoftheIMPACTstudy.
60
Factorsinfluencingantibioticprescribinginlongtermcarefacilities
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Factorsinfluencingantibioticprescribinginlongtermcarefacilities
Additionalfile.Topiclistsforphysician(A)andnursingstaff(B)interviews.
A)Topiclistforphysicianinterviews
Instruction:boldprintedtopicsrepresenttheessentialelementstobecoveredintheinterview;theremainingquestions
canbeusedtoraisefollowupquestions.[Instructionstointerviewerareprintedinitalics]
Infectiousdiseases
x
Canyoutellmesomethingabouttheoccurrenceofinfectiousdiseasesinresidentsofthisfacility?
x
x
x
Howoftendotheyoccur(incomparisonwithotherdiseases)?
Whichtypesofinfectiousdiseasesoccurmostoften?
Accordingtoyou,howdoestheoccurrenceofinfectiousdiseasesinthisfacilitycomparetothe
occurrenceofinfectiousdiseasesinotherhealthcaresettings(othernursinghomes/residentialcare
facilities,hospitals,generalpractices, etc.)
3
Antibiotics
x
Canyoudescribethemostrecentcaseinwhichyouprescribedantibiotics?
Listencarefullytowhichofthebelowmentionedtopicsareraised,andrelatetotheseinfollowupquestions
accordingly.Note:notallquestions(thosenotbolded)needtobecovered!
x Whataspectsofthiscaseresultedinyourdecisiontoprescribeantibiotics?Inotherwords,whichconsiderations
didyoumakepriortoyourdecisiontoprescribeantibiotics?
Incasetheclinicalpresentation/statusofthepatientisconsideredintheprescribingdecision:
(E.g.signsandsymptoms,additionaldiagnosticinformation,clinicalhistory)
x
Wastheclinicalpresentationclear?
x
Istheclinicalpresentationoften(also)clearinothercases?
x
Arethereanypatientgroupsinwhichtheclinicalpresentationisoftenlessclear?
x
Doyoufindproperdiagnosingdifficultiftheclinicalpresentationisambiguousornotclear?
Inthedescribedcase,whatinformationdidyouneedfromthenursingstaff?
x
Didyouindeedgetthisinformation?
x
Howdoyoufeelaboutthequalityoftheinformationinthiscase?Isthisinlinewithyouropinionmore
generally?
x
Arethereanydifferencesinthequalityofinformationifyouaskapatientforhis/hersymptoms
yourselfcomparedtoifyouobtainthisinformationviathenursingstaff?
x
Inyouropinion,isnursingstaffcapableofadequatelyassessingsignsandsymptomsofinfections?
x
Inyouropinion,doesnursingstaffadequatelyreportsignsandsymptomsofinfectionstothe
physicians?
x
Doestheprovisionofinformationbytelephoneaffectthequalityoftheinformation?
Incaseofinfluenceofthepatient,familyand/ornursingstaffontheprescribingdecision:
(ifthisdidnotappearfromthecasedescription,inquireaboutanyoccurrenceofinfluenceofthepatient,family
and/ornursingstaffmoregenerally,andaskforanexampleifapplicable).
x
Whichpreferenceswereexpressedbypatients,familyand/ornursingstaff?Aresuchpreferences
expressedmorefrequently?
x
Towhatextentdidthesepreferencesconcurwiththetreatmentyouwouldpropose?Dothey(also)
concurinothercases?
x
Doyouexperienceitas‘difficult’tohandlethepreferencesofpatients,familyand/ornursingstaff?Why
do/don’tyouexperiencethisas‘difficult’?Inwhichsituationsinparticular?
x
Doesthedurationorqualityofthephysicianpatientrelationshipaffectthewaypreferencesofpatients
andfamilyaredealtwith?Andhowso?
Incaseotherfactorsappearedtobeinvolvedintheprescribingdecision:
(E.g.theriskofdevelopmentofantibioticresistance,organizationalfactors(timepressure,staffshortage,staff
turnover,presence/availabilityofdiagnosticresources,financialconsiderations).
Thoroughlyquestionhowandwhythesefactorswereconsidered!
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Chapter3
x
Inretrospect,doyoufeelthatprescribingantibioticswastherightdecisioninthiscase?
x
x
x
x
x
x
x
x
x
x
Wasthischoicebasedonempiricalgrounds,ordidyouhaveanyinformationabouttheinfectiveagent
(cultureresult)atthetimeofprescribing?
Isyourprescribingoftenempirically/basedoninformationabouttheinfectiveagentinother
situationsaswell?
Whendoyoudecidetotakeaculture?
Whatpreventsyoufromtakingcultures?
Is…[infectiontypecase]aninfectiontypeforwhichyouoftenprescribeantibiotics?
x
x
x
x
Canyouexplainthis?Whydoyoufeelthiswas(not)agooddecision?
Incasetreatmenteffectivenesssupportedthefeelingthatprescribingantibioticswastheright
decision:
Basedonwhatdidyouconcludethatthetreatmentwaseffective?
Whatisyourunderstandingofa‘good’prescribingpattern?
(Basedonevidence,aformulary,routine,experience,observedeffectiveness,etc.)
Generallyspoken(notspecificallyforthiscase),inretrospect,doyouconsideryourdecisionto
prescribeantibioticsastheright/agooddecisionornottheright/agooddecision?
x
Canyouexplainthis?
Canyoudescribeasituationinwhichyoufelt,inretrospect,thatyourdecisiontoprescribe
antibioticswasnotagooddecision?Orthatyouwereindoubtaboutwhetheritwasagooddecision
ornot?
Doyoubelievethatthereareopportunitiestoimproveantibioticprescribingbyphysicians(including
yourself)?
x Canyougiveexamplesofsuchopportunities?
x Howcouldthisbeachieved?
x Doyoubelievephysiciansareopentosuchopportunities?
Whydidyouselectthespecificantibioticagentprescribedinthedescribedcase?
(E.g.formulary,patientallergies,patients’renalfunction,priorantibioticresistance)
x
x
Whyis/isn’tthisaninfectiontypeforwhichyouoftenprescribeantibiotics?
Forwhichinfectiontypesdoyoualsofrequently/morefrequentlyprescribeantibiotics?
Ingeneral,areantibioticsfrequentlyprescribedfortheresidentsofthisfacility?
x
Accordingtoyou,howdoestheoccurrenceofantibioticsprescribinginthisfacilitycompareto
theoccurrenceofantibioticprescribinginotherhealthcaresettings(othernursinghomes/
residentialcarefacilities,hospitals,generalpractices,etc.)
Sofar,wediscussedsituationsinwhichantibioticswereprescribed.Canyoualsodescribethemostrecentcase
[withaninfection]inwhichyoudidnotprescribeantibiotics?
x
x
x
Whydidyoudecidenottoprescribeantibiotics?
Canyoudescribeothersituationsinwhichyoudonotprescribeantibiotics?
Arethereanysituationsinwhichyoufinditdifficultnottoprescribeantibiotics?Canyoudescribe
thesesituations?Whydoyouexperienceitasdifficulttonotprescribeantibioticsinthesesituations?
(E.g.pressureoffamily(seealsopreviouspage),riskofnegativeoutcomeofinfection)
64
Factorsinfluencingantibioticprescribinginlongtermcarefacilities
Antibioticresistance
x
Canyoutellmesomethingabouttheoccurrenceofantibioticresistanceinthisfacility?
x
x
x
x
x
Howoftendoesitoccur?
Doyoubelievethereisanincreaseinantibioticresistance?Whatarethecauses?
Accordingtoyou,howdoestheoccurrenceofantibioticresistanceinnursinghomes/residentialcare
facilitiescomparetotheoccurrenceinhospitalsorthecommunity?
Inyouropinion,howlargeistheresistanceprobleminnursinghomes/residentialcarefacilities?And
howlargeintheNetherlandsingeneral?
Doyoubelievethatyouarewellawareofthedevelopmentswithregardtoantibioticresistance?If
not,whynot?
x
Doyou,asaphysician,experienceapersonalresponsibilityfortheemergenceofantibioticresistanceinthe
facility?Andinsocietyingeneral?
x
Whois/arealso/moreresponsiblefortheemergenceofantibioticresistance?
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Chapter3
B)Topiclistforinterviewswithnursingstaff
Instruction:boldprintedtopicsrepresenttheessentialelementstobecoveredintheinterview;theremainingquestions
canbeusedtoraisefollowupquestions.[Instructionstointerviewerareprintedinitalics]
Infectiousdiseases
x
Canyoutellmesomethingabouttheoccurrenceofinfectiousdiseasesinresidentsofthisfacility?
x
x
x
x
Dotheyoccuroften(incomparisonwithotherdiseases)?
Whichtypesofinfectiousdiseasesoccurmostoften?
Accordingtoyou,howdoestheoccurrenceofinfectiousdiseasesinthisfacilitycomparetothe
occurrenceofinfectiousdiseasesinotherhealthcaresettings(othernursinghomes/residentialcare
facilities,hospitals,generalpractices,etc.)
x
Whatisspecificforaurinarytractinfection?
x Whendoyoudecidetoperformadipsticktest?
Whatisspecificforarespiratorytractinfection?
Whatisspecificforaskinorwoundinfection?
Doyoubelievethatyou(andyourcolleagues)arewellcapableofassessingsignsandsymptomsof
infections?Why(not)?
x
x
x
x
Howdoyourecognizeaninfectioninaresident?
Canyoudescribewhenyoureportsignsandsymptomsofinfectiontoaphysician?
x
Whenisitimportanttoconsultaphysicianincaseofsignsandsymptomsofaninfection?
x Doyoufinditdifficulttodeterminewhenaphysicianshouldbeconsultedforaresident?
x Canyoudescribeanexampleofsituationsinwhichaphysicianissometimesconsultedtoosoon?
Andanexampleinwhichaphysicianisnotconsultedsoonenough?
Doyoubelievethatyouarewellcapableofreportinginformationaboutsignsandsymptomsof
infectionstoaphysician?
x Doestheinformationthatyouprovidehelpthephysicianinmakingdecisionsregardingthe
treatmentoftheinfection?
x Doyoufeelthatthephysicianfindstheinformationthathe/shereceivesimportant?
x Doyoubelievethatattimesyoucouldprovidemoreorbetterinformationtothephysician?Or,
bycontrast,providelessinformation?
x Howdoyoureporttheinformationtothephysician?Inperson,bytelephone,viawritten
communication?
x
x
Canyoudescribethemostrecentsituationinwhichyouconsultedaphysicianforapossibleinfectionina
resident?
x
x
x
x
x
x
x
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Fromwhichtypeofinfectiondidtheresidentsuffer?
Howdidyourecognizethisinfection?
Howdidyouinformthephysician?
Howdidthephysicianrespond?
Didyouexpectthephysiciantoinitiateaspecifictreatment?
Didthephysicianactaccordingtoyourexpectation?
Canyougiveexamplesofsituationsinwhichthephysiciandidanddidnotactaccordingtowhatyou
hadexpected?
Factorsinfluencingantibioticprescribinginlongtermcarefacilities
Antibiotics
x
Canyoutellmesomethingabouttheuseofantibioticsinthisfacility?
x
x
x
x
x
x
3
Canyougivesomeexamples?
Howcouldthisbeachieved?
Doyoubelievephysiciansareopentosuchactivities?
Dophysicians,attimes,notprescribeanantibiotic,whileyoubelieveitwouldbebetterifhe/shedidso?
(possibleoverlapwiththelastquestionofthesection‘infectiousdiseases’)
x
x
x
x
Canyougiveanexampleofasituationinwhichsignsandsymptomswererelieved,andofasituation
inwhichtheynot?
Inthesituationinwhichsignsandsymptomswerenotrelieved;accordingtoyou,whynot?
Inretrospect,doyouoftenbelievethatthedecisionofaphysiciantostartantibioticswasagood
decision?Why(not)?
x Whendoyoubelieveaphysicianshouldstartantibiotictreatment?
(E.g.whenyoufeelthepatientneedsantibiotics,whenindicatedbyguidelines,whenantibiotic
treatmentiseffective,etc.)
Couldphysiciansimprovetheirantibioticprescribinginanymanner?
x
x
x
x
Ifaresidentwithaninfectionreceivesantibiotics,towhatextentdoesthisalleviatethesignsandsymptoms?
x
x
Areantibioticfrequently/infrequentlyprescribedfortheresidents?
Doyouthinkthatthispatterndiffersfromothernursinghomes/residentialcarehomes,orother
healthcaresettingssuchashospitalsorgeneralpractices?
Forwhichtypeofinfectionareantibioticsprescribedmostfrequently?
Canyougiveanexample?
Doyouthenletthephysicianknowthatyoubelieveitwouldbebettertoprescribeantibiotics?And
howdoyoulethim/herknow?
Doyoufinditdifficulttoexpressyourdisagreementwiththephysician’streatmentdecision?
Canyouthinkofanynegativeconsequencesoftheuseofantibiotics?
(E.g.withregardtosideeffects,developmentofantibioticresistance,andcosts)
Thoroughlyquestionwhythementionedconsequencesareanegativeeffectofantibioticuse!
Antibioticresistance
x
Whenantibioticsareusedfrequently,antibioticresistancecanoccur.Canyouexplainwhatthismeans,according
toyou?
(Iftheydonotknow:antibioticresistancemeansthatbacteriathatcauseinfectionsarenotsusceptibleanymore
tospecifictypesofantibiotics,andconsequently,patientswiththeseinfectionscannotbetreatedanymorewith
thesetypesofantibiotics).
(Possibleoverlapwiththepreviousquestion)
x
Canyoutellmesomethingabouttheoccurrenceofantibioticresistanceinthisfacility?
x
x
x
x
Doesitoccuroften?
Doyoubelievethereisanincreaseinantibioticresistance?
Accordingtoyou,howdoestheoccurrenceofantibioticresistanceinnursinghomes/residentialcare
facilitiescomparetotheoccurrenceinhospitalsorthecommunity?
Inyouropinion,howlargeistheresistanceprobleminnursinghomes/residentialcarefacilities?And
howlargeintheNetherlandsingeneral?
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